EJPC @ a glance: focus issue on exercise, physical activity, and sports cardiology

This issue of the European Journal of Preventive Cardiology focuses on exercise, physical activity (PA), and sports cardiology. Physical fitness, the capacity to perform PAs without excessive fatigue and with sufficient energy to enjoy them, is often confused with PA itself, which refers to any type of bodily movement. In a clinical research article entitled ‘Physical activity and physical fitness in prediction of all-cause mortality and age at death in European extinct cohorts of middle-aged men followed for 60 years’, Menotti et al.1 analysed the impact of physical fitness and PA on all-cause mortality in seven European cohorts. The study included middle-aged men, who were followed until the virtual extinction of the cohorts (60 years). Fitness levels were assessed by the ‘FitScore’, which included measurements of arm circumference, heart rate, and vital capacity. The results demonstrated that both PA and fitness have significant predictive power for all-cause mortality, with FitScore being a more powerful predictor than the type of PA. Pre-admission PA emerges as a prognostic marker in patients with acute cardiac event. In a clinical research article entitled ‘Impact of pre-admission physical activity on benefits of physiology-guided complete revascularization in older patients with myocardial infarction: insights from the FIRE trial’, Pavasini et al.2 performed a secondary analysis of the randomized FIRE trial, which enrolled elderly patients with myocardial infarction (MI) and randomized them to receive either multi-vessel physiology-guided revascularization or culprit-only strategy. They showed that patients with light or vigorous PA had proportionally lower rates of composite outcomes (death, MI, stroke, or coronary revascularization). The prognosis was better after physiology-guided complete revascularization (vs. culprit-only strategy), independent of the level of PA. In clinical practice, it is common to encounter athletes with higher coronary artery calcium (CAC) scores, a phenomenon associated with high-intensity training. This is linked to shear stress on coronary vasculature and potentially transient inflammation during intense exercise. In a clinical research article entitled ‘Coronary artery calcification and high-volume physical activity: role of lower intensity vs. longer duration of exercise’, Pavlovic et al.3 addressed the impact intensity and duration of exercise on CAC. They analysed the data from 23 383 apparently healthy men who completed a PA questionnaire and underwent CAC scanning as part of a preventive examination. Self-reported PA was categorized into four groups based on average intensity and weekly duration. They found that a higher average intensity of PA was associated with lower mean CAC and a lower relative risk of increased CAC. Conversely, a longer weekly duration of PA was significantly associated with greater mean CAC and a higher risk of increased CAC. The authors concluded that elevated CAC was linked to lower average intensity and longer duration of PA in men, offering new insights into the complex relationship between leisure-time PA behaviours and the coronary risk. In the last decades, an increase in participation in sports and fitness activities, combined with heightened competitiveness and societal pressures for physical performance and appearance, has contributed to the rise in anabolic steroid use among amateur and professional athletes. In a clinical research article titled ‘Elevated interleukin 8 and matrix metalloproteinase 9 levels are associated with myocardial pathology in users of anabolic-androgenic steroids’, Gregersen et al.4 addressed the anabolic-androgenic steroids (AAS) impact on the myocardium. They measured blood concentrations of matrix metalloproteinase 9 (MMP-9), an extracellular matrix remodelling marker, and interleukin 8 (IL-8), an inflammatory marker, in 93 present or past AAS users, matched with 54 controls. Both MMP-9 and IL-8 levels were significantly higher in current AAS users vs. former users and control subjects. Using mediation analysis, they demonstrated that MMP-9 and IL-8 concentrations mediate the impact of AAS on myocardial hypertrophy. These findings reveal the impact of AAS on inflammation and extracellular matrix remodelling, mediating cardiovascular side effects in AAS users. Sudden cardiac death (SCD) is an uncommon but tragic event among athletes. Most of the existing data focus primarily on white athletes. In a clinical research article entitled ‘Ethnicity and sudden cardiac death in athletes: insights from a large United Kingdom registry’, Finocchiaro et al.5 address potential differences in aetiologies of SCD among athletes of diverse ethnicities. They studied 848 autopsied athletes, victims of SCD between 1994 and 2022. Overall, sudden arrhythmic death was the most prevalent cause of SCD across all ethnicities. The study found that arrhythmogenic and other cardiomyopathies were more common among Blacks, while atherosclerotic coronary artery disease was more prevalent in Asians with a strong association with exercise-induced SCD. These findings underscore the necessity for personalized prevention approaches based on ethnic-specific risks and highlight the importance of comprehensive cardiac screening to detect asymptomatic conditions that could lead to SCD. In this regard, pre-participation screening (PPS) of athletes is crucial for identifying conditions at risk of SCD. The 12-lead electrocardiogram (ECG) has a superior sensitivity in PPS compared with history and physical examination alone. However, structural and electrical remodelling due to athletic training can produce ECG abnormalities that mimic heart diseases, reducing the ECG’s specificity. Specific criteria for interpreting athletes’ ECGs have been developed to address this issue, although low QRS voltages (LQRSV) in limb leads and QRS fragmentation (FQRS) are not included in the current criteria. In a clinical research article entitled ‘Prevalence and determinants of low QRS voltages and QRS fragmentation in children and adolescents undergoing sports pre-participation screening’, Graziano et al.6 investigated the prevalence and determinants of LQRSV and FQRS in young, apparently healthy athletes undergoing PPS (Figure 1). After the analysis of 2140 consecutive ECGs, they found that LQRSV and FQRS are rare and not related to the type or intensity of sports activities. Low voltages in limb leads can indicate non-ischaemic left ventricular fibrosis, increasing the risk of SCD. This study found a low prevalence of LQRSV at 0.2%, with no association to the type of sports, suggesting LQRSV is not common or training-related. Additionally, FQRS, caused by altered depolarization in diseased myocardium, was found in only 0.5% of athletes, with no correlation to sex, body mass index, type of sports, or training intensity. One athlete with FQRS was diagnosed with mitral valve prolapse, indicating that the clinical significance of FQRS in athletes requires further investigation. The authors conclude that while LQRSV and FQRS are rare in young athletes, their presence may necessitate additional testing (i.e. magnetic resonance imaging) to rule out underlying disease, particularly when other abnormalities are present. ‘Prevalence and determinants of low QRS voltages and QRS fragmentation in children and adolescents undergoing sports pre-participation screening’ by Graziano et al. FQRS, fragmented QRS; LQRSV, low QRS voltage. The benefits of PA in the youth on cardiometabolic and vascular health are well known. However, longitudinal data on the impact of lifestyle factors, such as device-measured sedentary time, on cardiac morphology in the paediatric population are scarce. In a clinical research article entitled ‘Accelerometer-based sedentary time and physical activity from childhood through young adulthood with progressive cardiac changes: a 13-year longitudinal study’, Agbaje7 analysed the cardiac structure and function changes over 7 years in 1682 children aged 11 years. Increased sedentary time was associated with an increase in cardiac mass, while light PA was related to a decrease in cardiac mass (Figure 2). This study supports the major role of PA in cardiac health among (pre-)adolescents. ‘Accelerometer-based sedentary time and physical activity from childhood through young adulthood with progressive cardiac changes: a 13-year longitudinal study’ by Agbaje. Light PA, light physical activity; MVPA, moderate-to-vigorous physical activity; ST, sedentary time. Cardiovascular diseases (CVDs) remain a leading cause of mortality. Effective and economically viable prevention strategies are critical. The clinical research article entitled ‘Cost-effectiveness of Mediterranean diet and physical activity in secondary cardiovascular disease prevention: results from the UCC-SMART cohort study’ by Bonekamp et al.8 explores the economic benefits of lifestyle interventions in patients with established CVD. Through a cost-utility analysis on a cohort of 100 000 patients derived from the Utrecht Cardiovascular Cohort, the authors demonstrate that combining a Mediterranean diet with PA not only improves health outcomes but also leads to significant cost savings. In a clinical consensus statement of the European Association of Preventive Cardiology and the European Association of Rehabilitation in Chronic Kidney Disease, entitled ‘The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3–G5 and G5D’, Kouidi et al.9 provide a concise overview of the available evidence on PA in individuals with chronic kidney disease (CKD). The authors highlight the beneficial impact of PA and training in patients with CKD on various aspects of cardiovascular health, including blood pressure, cardiovascular function and structure, and prevention of arrhythmias. They propose an algorithm for exercise prescription in patients with CKD, including those under dialysis. Additionally, they emphasize existing gaps in this field and call for closer collaboration between patients, general practitioners, (sports) cardiologists, nephrologists, and physiotherapists/exercise physiologists. The editors hope this issue of the European Journal of Preventive Cardiology will captivate its readers.